Margueritta S. El Asmar,¹ Joseph J. Naoum,² and Elias J. Arbid^2*

Abstract

Vascular calcification, a cause of cardiovascular morbidity and mortality, is an actively regulated process involving vitamin K dependent proteins (VKDPs) among others. Vitamin K is an essential micronutrient, present in plants and animal fermented products that plays an important role as a cofactor for the post-translational γ-carboxylation of glutamic acid residues in a number of proteins. These VKDPs require carboxylation to become biologically active, and they have been identified as having an active role in vascular cell migration, angiogenesis and vascular calcification. This paper will review the process of vascular calcification and delineate the role that vitamin K2 plays in the modulation of that process, through the activation of VKDPs. One such VKDP is Matrix Gla Protein (MGP), which when activated inhibits osteogenic factors, thereby inhibiting vascular and soft tissue calcification.

Keywords: Vitamin K; Vitamin K2; Menaquinone; Vascular Calcification; Matrix glutamate-Protein (MGP); Warfarin; Vitamin K antagonists.

Aiman Al Wahaibi,¹ Saada AL-Adawi,¹ Wafa AL-Shehhi,¹ Syed Gauhar A. Rizvi,² Nasser Al-Kemyani,³ Khalfan Al-Amrani,⁴ and Murtadha Al-Khabori^5*

Abstract

Objective: This study aims to evaluate the knowledge and attitudes of Oman Medical Specialty Board (OMSB) residents towards Evidence-Based Medicine (EBM).

Methods: This cross sectional study was conducted on all OMSB residents through a self-administered online questionnaire between October 2012 and March 2013. An electronic survey was designed to identify and determine residents' knowledge and attitudes toward the use of EBM.

Results: The survey was completed by 93 (21%) OMSB residents, 76 (82%) of whom took part in continuing education courses and 50 (54%) belonged to professional practice-oriented organizations. On average, the residents were reportedly involved in patient care for approximately 70% (Standard Deviation [SD] 17%) of their time, while 14% (SD 12%) participated in research activities. The results showed that 53 respondents (57%) were competent users of medical search engines compared to 23 residents (25%) who rated their skills as neutral. Sixteen percent of the respondents strongly agreed and 46% only agreed that the facility supports the use of current research in practice. Fourteen percent strongly agreed and fifty-three percent only agreed that the foundation of EBM is part of OMSB academic preparation. On the other hand, 17% of the respondents thought that insufficient time is always a barrier against EBM, while another 27% perceived insufficient time as a usual barrier. The lack of information resources was reported to always be a barrier in 11% of the respondents while 32% thought that it usually acts as a barrier.

Conclusion: Time constraints and skills in EBM were found to be the two major obstacles. This study was, however, limited by the low response rate of the survey; thus larger studies with a previously validated questionnaire should be conducted in the future.

Keywords: Evidence-Based Medicine; Attitude; Knowledge; Residents.

Dariush Haghmorad,¹ Mohammad B.Mahmoudi,¹ Mahmoud Mahmoudi,² Shahrzad Z.T. Rab,¹ Maryam Rastin,¹ Hamid Shegarfi,³ Gholamreza Azizi,⁴ and Abbas Mirshafiey⁵

Abstract

Objective: Multiple sclerosis (MS) is the most common inflammatory disease of the CNS. Experimental autoimmune encephalomyelitis (EAE) is a widely used model for MS. In the present research, our aim was to test the therapeutic efficacy of Calcium (Ca) in an experimental model of MS.

Methods: In this study the experiment was done on C57BL/6 mice. EAE was induced using 200 μg of the MOG_35-55 peptide emulsified in CFA and injected subcutaneously on day 0 over two flank areas. In addition, 250 ng of pertussis toxin was injected on days 0 and 2. In the treatment group, 30 mg/kg Ca was administered intraperitoneally four times at regular 48 hour intervals. The mice were sacrificed 21 days after EAE induction and blood samples were taken from their hearts. The brains of mice were removed for histological analysis and their isolated splenocytes were cultured.

Results: Our results showed that treatment with Ca caused a significant reduction in the severity of the EAE. Histological analysis indicated that there was no plaque in brain sections of Ca treated group of mice whereas 4 ± 1 plaques were detected in brain sections of controls. The density of mononuclear infiltration in the CNS of Ca treated mice was lower than in controls. The serum level of Nitric Oxide in the treatment group was lower than in the control group but was not significant. Moreover, the levels of IFN-γ in cell culture supernatant of splenocytes in treated mice were significantly lower than in the control group.

Conclusion: The data indicates that Ca intervention can effectively attenuate EAE progression.

Keywords: MS; CNS; EAE; Calcium; Nitric Oxide.

Sana Sadiq Sheikh,^1* and Syed Asad Ali²

Abstract  

Objective: To determine the factors associated with retaining the vaccination card among care takers of 12-59 months old children in Karachi, Pakistan.

Methods: This was an analytical cross-sectional study in Karachi. Households were randomly selected throughout a multistage cluster sampling technique. Data was collected for 504 children of 12- 59 months of age. Questionnaire was administered to caretakers to gather information regarding the children’s vaccination status, socio-demographic characteristics and reviewing their vaccination cards. Statistical analysis was done by SPSS 19 using logistic regression.

Results: Among 462 vaccinated children, caretakers of 33% provided vaccination cards. Odds of card retention decrease if the caretaker has a large household i.e., >5 people sharing one room (AOR 0.277, 95% CI: 0.096, 0.797) and if the child is of four to five years of age (AOR 0.544, 95% CI: 0.305, 0.970). Gender of the child, and the caretaker’s education and access to electronic media were not significant predictors of vaccination card retention in our study.

Conclusion: Our study showed that vaccination card retention for children 12-59 months of age was low (33%) in Karachi. There is a need to educate caretakers of young children regarding the importance of keeping vaccination card and to disseminate this information through healthcare providers. Improving vaccination card retention is one of the key measures which will help towards accurately estimating coverage and to inform health policy decisions.

Keywords: Predictors; Vaccination Card; Retention; Under Five; Pakistan.

Alieh Zamani Kiasari,¹ Abolfazl Firouzian,^1* Afshin Gholipour Baradari,¹ Hamid Sharif Nia,² and Seyed Hosein Moosavi Kiasari³

Abstract

Objective: Nitrous oxide is a common inhalation anesthetic agent in general anesthesia. While it is widely accepted as a safe anesthetic agent, evidence suggests exposure to this gas, leads to hyperhomocysteinemia. The present study aimed to evaluate the effects of single-dose intravenous infusions of vitamin B12, before and after the induction of nitrous oxide anesthesia on homocysteine levels after the surgery.

Methods: This double-blind randomized controlled trial was conducted on 60 patients who were scheduled for elective surgery under general anesthesia, presumably lasting for more than two hours. The subjects were randomly allocated to three groups of 20. For the first group, vitamin B12 solution (1 mg/100 ml normal saline) and 100 ml of normal saline (placebo), were infused before and after the induction of anesthesia, respectively. The second group received placebo and vitamin B12 infusion before and after the induction of anesthesia, respectively. The third group received placebo infusions at both times. Homocysteine levels were measured before and 24 hours after the surgery.

Results: The mean homocysteine and vitamin B12 levels were significantly different within the three groups (p<0.001). In patients who had been infused with vitamin B12 before the surgery, homocysteine levels were significantly lower than the other two groups. In the placebo group, homocysteine levels significantly increased after the surgery.

Conclusion: Nitrous oxide causes hyperhomocysteinemia after general anesthesia. Since vitamin B12 infusion is a safe and inexpensive method to decrease homocysteine levels in these patients, it may be recommended for patients undergoing nitrous oxide anesthesia to be used before induction of anesthesia.

Keywords: Nitrous oxide; Homocysteine; Vitamin B12.

Fatma Ibrahim Al Hinai* and Saleh Saif Al Hinai

Abstract

Objectives: Postnatal Depression (PND) is a major health problem. It has a serious impact on the mother, her child and family. Studies have shown wide diversity of its prevalence across different cultures. Its epidemiology and its associated risk factors in Oman remain unknown. The objectives of this study were to estimate the prevalence of PND in the Al-Dakhliya governorate and to identify the risk factors contributing to the development of PND.

Methods: A total of 282 Omani women who gave birth in September 2010 were part of a prospective study conducted in Al-Dakhliya governorate. An Arabic version of the Edinburgh Postnatal Depression Scale (EPDS) was used to assess the PND symptoms. Negative binomial regression model was used to identify the independent predictors of outcome (EPDS scores at two and eight weeks post-delivery) due to the non-normal distribution of the EPDS scores.

Results: The study results showed that at two weeks, 13.5% of mothers and 10.6% at eight weeks had EPDS scores of 13. Bahla district was found to have the highest number of depression scores among the other six districts in the governorate. It was found that mothers less than 25 years of age were more likely to report high EPDS scores. The independent predictor was work difficulties both at two and eight weeks postpartum (p=0.001 and p=0.019, respectively). At two weeks postpartum, significant association was also found between depression scores and conflict with a family member (p=0.017), and sickness of a family member (p=0.010). There was no significant association between EPDS scores and socio-demographic, obstetric or other clinical factors.

Conclusion: This study is among the few studies looking at PND in the Middle East and shows on average 12% of Omani women are at a high risk of developing PND (EPDS scores of ≥13). Although the study findings were based on an unvalidated version of EPDS for Omani women, they can be used as a basis for further research.

Keywords: Postnatal depression; Arabic; Risk factors.

Rajeeva Rivikath Pieris,^1* Hilal Ali Al-Sabti,¹ Qasim Saleh Abdullah Al-Abri,¹ and Syed Gauhar Alam Rizvi²

Abstract

Objectives: To identify the pattern of prevalence of risk factors in patients presenting for coronary artery bypass grafting at a single center in Oman.

Methods: All patients who had coronary artery bypass grafting between March 2008 to March 2010 were included and data were obtained from history and laboratory investigations. The prevalence rates of eight conventional risk factors are presented as a retrospective single center observational study.

Results: Out of 146 total patients, 107 (73.29%) were male. The age ranged from 31 to 87 years old. The mean age was 58.18 ± 10.08 years (males = 56.81 ± 10.42, females = 61.95 ± 7.97). Hypertension was present in 119 patients (81.51%), 115 patients (78.77%) had dyslipidemia, 107 patients (73.29%) were male, 79 patients (54.11%) had diabetes mellitus, 70 patients (47.95%) were over the age of 60 years, 41 patients (28.08%) gave a history of smoking, 31 patients (21.23%) were obese, and 19 patients (13.01%) gave a positive family history.

Conclusions: The most common risk factor was hypertension, followed by dyslipidemia, male gender, diabetes mellitus, old age, smoking, obesity and positive family history; 87.7% had three or more risk factors. The females in this study were older than the males and had more risk factors at presentation. The most common combination of factors seen together was diabetes, hypertension, dyslipidemia and male gender.

Keywords: Coronary artery disease; Coronary heart disease; Risk factors; Atherosclerosis; Epidemiology; Oman.

Rashid Al Abri,^1* Arif Ali Kolethekkat,¹ Michael O. Kelleher,² Lynn M. Myles,³ and Michael A. Glasby³

Abstract

Objective: to determine whether the administration of Ciliary Neurotrophic Factor (CNTF) at the site of repaired facial nerve enhances regeneration in the adult sheep model.

Methods: Ten adult sheep were divided into 2 groups: control and study group (CNTF group). In the CNTF group, the buccal branch of the facial nerve was transected and then repaired by epineural sutures. CNTF was injected over the left depressor labii maxillaris muscle in the vicinity of the transected and repaired nerve for 28 days under local anesthesia. In the CNTF group, the sheep were again anesthetized after nine months and the site of facial nerve repair was exposed. Detailed electrophysiological, tension experiments and morphometric studies were carried out and then analyzed statistically.

Results: The skin CV min, refractory period, Jitter and tension parameters were marginally raised in the CNTF group than the control but the difference was statistically insignificant between the two groups. Morphometric indices also did not show any significant changes in the CNTF group.

Conclusion: CNTF has no profound effect on neuronal regeneration of adult sheep animal model.

Mohd Riyaz Lattoo,¹ Abdul Majeed Dar,¹ Mohd Lateef Wani,^2* Mohd Akbar Bhat,¹ Abdul Gani Ahangar,¹ Gh Nabi Lone,¹ Shyam Singh,¹ Muzaffar Zaman,¹ and Reyaz Ahmad Lone¹

Abstract

Objective: The aim of this study was to evaluate the trans-axillary surgical approach in patients with thoracic outlet syndrome.

Methods: This retrospective study is comprised of data acquired from January 1998 until Oct 2008. Case histories of all the patients were reviewed from the Medical Records Department of Sher-i-Kashmir Institute. Relevant information and follow-up of the patients was carried out by examining the relevant clinical notes available by telephone interviews and personal contact whenever possible. All data was compiled and analyzed statistically.

Results: There were a total of 139 patients. The female: male ratio was about 6:1. Pain was the most common presenting symptom followed by weakness and parasthesia. Nerve conduction velocity was abnormal in 111 patients. Twenty-eight patients had abnormal Doppler study of subclavian vessels. Preoperative symptoms persisted in 13 patients. Overall, 126 patients showed improvement in symptoms and no recurrence or persistence of symptoms on follow-up examination.

Conclusion: Trans-axillary approach provides a good exposure and cosmesis in patients with thoracic outlet syndrome. It should be considered as the gold standard in the management of thoracic outlet syndrome.

Seema Singhal,^1* Abha Singh,² Chitra Raghunandan,³ Usha Gupta,⁴ and Seema Dutt⁵

Abstract

The role of transcatheter arterial embolization in the management of obstetric emergencies is relatively new and not so commonly used. In the following series, the efficacy of this technique in situations such as scar site ectopic pregnancy, antepartum and postpartum obstetric hemorrhage, especially in the presence of coagulation derangement is presented.

Keywords: Uterine artery embolization; Scar site ectopic pregnancy; Antepartum hemorrhage; Post partum hemorrhage; Transcatheter arterial embolization.

Mehmet Incedayi,¹* Selahattin Ozyurek,² Serkan Aribal,³ Kenan Keklikci,⁴ and Guner Sonmez¹

Abstract

This is a case of a 17-year-old boy who was admitted to the clinic suffering from right hip-inguinal region pain which began after a soccer match. He had an avulsion fracture in the anterior inferior iliac spine and CT/MR images showed similarities to a bone tumor. These fractures are especially seen in the apophyses which are within the ossification process. The radiological appearance of these fractures during the healing period may be involved with bone tumors. In the control MRI of the patient after one year, the fracture was almost healed completely. Treatment is generally conservative. Good results have been reported with rest, analgesic and anti-inflammatory drugs. Familiarity with radiological findings of these avulsion fractures in this region not only protects the patient from invasive procedures but also avoids the involvement of the practitioner in legal consequences resulting from a misdiagnosis of sarcoma.

Keywords: Avulsion fracture; Pelvic apophyses; MRI.

Imran Hafeez,* Mohd S. Alai, Khurshid Iqbal, Khursheed Aslam, Ajaz Lone, Irfan A. Bhat, and Muezza Samer

Abstract

Lymphoma involving the heart is rare. This is a case report on non-Hodgkin lymphoma where the patient presented for the first time with heart failure and severe left ventricular systolic dysfunction due to lymphoma infiltrating the heart muscle and had simultaneous bilateral involvement of kidneys. This type of presentation has never been described in world literature and is the first reported case.

Keywords: Lymphoma; Heart failure; Left ventricular systolic dysfunction.

Rani A. Bhat,^1* Melissa Teo,² and Akhil Krishnanand Bhat³

Abstract

Prevalence of persistent endometriosis in women after menopause without any hormonal replacement therapy is very rare. This is a case of a woman with previous history of total hysterectomy and bilateral salpingo-oophorectomy for endometriosis who presented with hemoperitoneum, vaginal bleeding, pelvic mass, and pulmonary thromboembolism mimicking as rectovaginal septum carcinoma. This is the first case report with a unique mode of presentation wherein the patient presented with hemoperitoneum requiring emergency embolization of the vessel to stabilize the patient. She underwent en bloc resection of the tumor with high anterior resection of the rectum. Histopathology confirmed endometriosis.

Keywords: Endometriosis; Ovarian cancer; Menopause.

Mohammed Al Ghafri,* Ibtisam Al Sidairi and Madhavan Nayar

Abstract

Delayed herniation of the abdominal contents through a congenital diaphragmatic hernia may occur beyond the neonatal period. This report describes a 9-week-old female baby who presented with excessive crying, irritability and respiratory distress secondary to late presentation of left-sided congenital diaphragmatic hernia. The chest radiograph showed tension gastrothorax. She underwent surgical reduction of the hernia. She made an excellent recovery and was discharged a few days after the operation. It is assumed that sudden increase of the intra-abdominal pressure caused herniation of abdominal content through a pre-existing diaphragmatic defect. This report aims to increase the awareness of this condition among physicians and pediatric surgeons to allow early diagnosis and management.

Keywords: Late presentation of diaphragmatic hernia; Respiratory distress; Gastrothorax; Chest radiograph.

Reza Faridhosseini,¹ Farah Jabbari,¹ Afshin Shirkani,² Mohammad Reza Zandkarimi,³ Hadis Yousefzaedh,⁴ Maryam Sahebari,⁵ and Reza Basiri⁶

Abstract

Behcet’s disease is a multi-systemic inflammatory disorder with cutaneous acneiform eruptions, orogenital aphthae, uveitis, arthritis and systemic vascular inflammation. One of the rare vascular manifestations is thoraco-abdominal aortic and pulmonary aneurysm that is associated with high risk of morbidity and mortality. We report a 36-year-old man with chronic cough, hemoptysis, significant weight loss, and orogenital ulcers from one year before referral. Initial assessments revealed multiple parahillar nodules in chest X-ray, chronic inflammatory anemia, erythrocyte sedimentation rate more than 100, and positive Human Leukocyte Antigen B5 and B51. Evaluation for infection and malignancies was unremarkable. Open exploratory lung study showed multiple pulsatile nodules in both lungs. AMIGO computed tomogram confirmed multiple right and left pulmonary artery aneurysms and impending to rupture aneurysm at subdivision of inferior mesenteric artery. After beginning of three methylprednisolone and cyclophosphamide pulse doses, the clinical aspect of the patient dramatically improved. Although pulmonary aneurysm is a rare manifestation of Behcet’s disease and it is more infrequent in the distal branches, it can be seen in patients presenting with inflammatory disease and respiratory manifestations and with Behcet’s disease diagnosis. Corticosteroid pulse-therapy could be considered as the first line of medical treatment in these patients.

Keywords: Behcet’s disease; Aneurysm; Pulmonary Artery; Inferior mesentric artery; Medical treatment.

Muhammad Usman Shams,* Raees Abbas Lail, Ehsan Ullah, and Abdul Hannan Nagi

Abstract

Xeroderma pigmentosum is an uncommon inherited autosomal recessive disorder. Affected patients have a 2000-fold amplified risk of skin cancer. There is an inability to repair the damage to genetic material caused by ultraviolet light. Basal cell carcinoma is the most commonly associated carcinoma followed by squamous cell carcinoma and melanoma. It is a highly mutilating disorder where occurrence of multiple cancers and repeated surgical treatments result in serious psycho-social implications. We present a case of diagnosed xeroderma pigmentosum in a 25 year old male who presented with multiple lesions and non-healing ulcers on face. Four surgical specimens from left lower eyelid, chin, right cheek and upper lip were taken for histopathological diagnosis. Microscopic examination revealed five different tumors from biopsies of these sites - specimen from right cheek revealed two morphologically distinct tumors. The tumors include basosquamous carcinoma, nodular basal cell carcinoma, adenoid basal cell carcinoma, malignant melanoma and cavernous hemangioma. 

Keywords: Xeroderma pigmentosum; squamous cell carcinoma; basal cell carcinoma; malignant melanoma; cavernous hemangioma.

Said Al Hanshi,* Mohammed Al Ghafri, and Suad Al Ismaili

Abstract

We describe in this case report one month old baby admitted to our Pediatric Intensive Care Unit (PICU) with severe pertussis pneumonia. The baby was deteriorating despite being on supportive management including High Frequency Oscillator ventilation (HFOV). However, she showed dramatic improvement after exchange blood transfusion (ET) and was discharged home. We hope that this report will add to the previously published experiences in management of severe pertussis. It will also alert general physicians about pertussis pneumonia and the importance of early referral and abrupt management for a better prognosis.

 Keywords: Severe pertussis; leukocytosis; whole blood exchange transfusion; leukopheresis; pneumonia.

Latifa M. Baynouna,^1* Nico JD. Nagelkerke,² Thuraya A. Al Ameri,¹ Sanaa M. Zein Al Deen,¹ and Habiba I. Ali³

Abstract

Objectives: This study aims to study determinants for the control of diabetes and hypertension in Al Ain Ambulatory Healthcare patients.

Method: This is a cross sectional observational study of patients attending ambulatory healthcare centers in Al Ain, United Arab Emirates in 2009. From a yearly audit evaluating the care of patients with diabetes and hypertension, the determinants for improved diabetes and hypertension outcomes were identified from a total of 512 patients and its association with glycemic and blood pressure control were studied.

Results: From all variables studied, only the clinic where the patient was treated helped predict both improved blood sugar and blood pressure control. For patients with diabetes, poor control the year before (p<0.001), the number of chronic disease clinic visits (p=0.042) and triglyceride levels (p=0.007) predicted worse control of diabetes. A predictor of poor control of blood pressure (p<0.001) for patients with hypertension was poor control of blood pressure in the year before.

Conclusion: In this population, the healthcare system and the team played major roles as determinants in the control of patient’s diabetes and blood pressure more than any of the other factors examined.

Keywords: Diabetes; Hypertension; Quality Care.

Vaidyanathan Gowri,* Maryam Al Shukri, Maha Al Khaduri and Lovina Machado

Abstract

Objective: To study the clinical and histological nature of benign adnexal masses managed surgically.

Methods: A retrospective descriptive study in a teaching hospital in Oman of all the women who had surgical management of benign adnexal masses from January 2008 to May 2012. Data pertaining to age, parity, presenting symptoms, imaging and tumor markers performed and the surgical intervention done on those women with benign adnexal masses was collected from the electronic health records of the patients.

Results: There were 198 women during this period operated for benign adnexal masses. The most common benign neoplasm was mature teratoma of the ovary followed by endometriosis. Conservative surgery in the form of ovarian cystectomy was necessary in three fourths of women and in about just less than 50% of women, the procedure was completed laparoscopically.

Conclusion: The most common benign tumor was teratoma but laparoscopic approach, which is the standard of care in these women, was possible only in just about 50% of the women.

Keywords: Adnexal masses; Benign; Laparoscopy; Laparotomy; Surgery.